Today, we cherish local hospitals and the services they offer, even though we might criticise their shortcomings. Despite arguments for consolidating some specialist services to promote better care, for example, often the mere whisper of a closure can whip up outrage.

The importance given to local hospitals reflects an understanding of their history and role in modern medicine. The popular narrative suggests that the growing importance of the hospital in the 18th and 19th centuries was the result of medical progress, with the hospital acting as a place where new ways of thinking about the body, new technologies and new procedures were developed. But this is only half the story.

Famous hospitals such as St Thomas’s or St Bartholomew’s in London had existed in Britain before 1700, but the 18th century witnessed significant changes in the nature of hospital provision and a hospital boom, often called the voluntary hospital movement. Although London was at the epicentre of this boom, 38 provincial hospitals had opened by 1800 and 60 years later there were 230 voluntary hospitals in Britain.

New types of hospital also emerged: the teaching hospital, the specialist hospital and later the cottage hospital, which extended hospital provision in towns and rural areas. Specialist hospitals were controversial (as they still are) but by the 1890s most large cities could boast several institutions for all manner of ailments, organs and patients.

By the last quarter of the 19th century, hospitals had also become central to professional career structures and networks. They provided a home for elite practitioners as well as for a new style of nursing associated with Florence Nightingale. Reforms aided the idea that the hospital was an important place to receive medical care.

But this narrative about the rise of the hospital and their transformation into modern medical institutions conceals a more complex history; one in which medicine and doctors were often less important than might first be assumed.
Many would think that the dramatic growth in hospital provision during the 18th and 19th centuries was driven by changes in medicine often characterised as “hospital medicine”. This was associated with observation, physical examination, morbid anatomy and dissection – a style that placed the hospital ward and postmortem room at the centre of medical knowledge. As doctors looked at disease in new ways, hospitals provided both resources for the construction of medical knowledge, for medical education, and later for the laboratory.

In response to these shifts in medical understanding, hospitals emerged as sites for training, innovation and experimentation (particularly in physiology and pathology). They became associated in the public mind with advances in clinical practice, particularly in surgery following the introduction of new methods of pain control (anaesthetics) and wound management (antiseptics).

Pain, gain and social transformation

While not denying the importance of these changes, a more nuanced interpretation would take into account social, economic and professional forces. For example, the specialist hospitals were shaped as much by changes in medicine as they were by medical practitioners seeking to advance their careers through an institutional appointment. In the highly competitive medical marketplace that existed in the 19th century, founding a specialist hospital – as Frederick Salmon did with St Mark’s Hospital in London – offered opportunities for professional advancement at a time when hospital consultancy posts were monopolised by a small urban elite.

The importance of social and economic factors is particularly striking in explaining the voluntary hospital movement, which was underwritten by the transformations that came from industrialisation and urbanisation. The boom in hospital provision owed much to the growth of towns, social mobility, an expanding urban middle class, and an upsurge in charitable effort directed at aiding the sick but “deserving” poor.

Until the 1850s, hospitals were a focus for civic pride and local charity, and were primarily social not medical institutions. They were a major channel for the upsurge in philanthropic initiatives that characterised the 18th and 19th centuries, with supporters giving for a range of altruistic and selfish reasons. Much like today, how to finance hospital provision become an important issue. As the cost of care outpaced charitable resources, crucial questions were raised about the boundaries between charity and the state.

Provision was also influenced by religious revivalism in the late 1700s and early 1800s, as well as by Enlightenment thinking with its emphasis on the importance of social progress and prosperity. Social commentators and medical practitioners established a link between illness and poverty; it was argued that curing illness would prevent poverty, return the labourer to work, and contribute to national wealth. These ideas were manifested in hospital foundations. Looking at it this way, medicine often takes second place to social and economic factors in the expansion of hospitals.

Medical transformations?

Changes in surgery and the growing importance of the lab, have traditionally been assumed by historians to be at the heart of transforming in hospital medicine. For example, a shift has been detected from the early 19th century when few operations were carried out to surgical intervention dominating the hospital by the early 20th as new procedures were introduced and new operating theatres were built. In response, the public started to feel that hospitals were the best place to receive treatment, and after 1870 the number of people opting to pay for a bed grew.

But here again the extent of this transformation shouldn’t be overstated. Institutional cultures and practises were slow to change. Hospitals were more often characterised by their dirty and unruly nature than their medical care. In the 19th century, changes in medicine did not radically or immediately alter the treatments available in hospitals, especially outside major cities. Hospital care still frequently meant bed-rest and nursing rather than therapeutic intervention.

All of this tells us that medical advances alone do not drive progress; that hospitals evolved from a mix of social, economic and professional changes. Such an understanding of history – the importance of context, the questioning of ideas of progress – would not appear in education secretary Michael Gove’s vision of what is important in history.

But more than this, at a time when the NHS is undergoing another bout of controversial reforms, we should keep in mind how the hospitals we see as integral to the NHS were not just a feature of medical or political factors, but reflected important social, economic and cultural forces that made them essential to healthcare.